Nantucket

The commercial pilot stated that, shortly after taking off for a cross-country, personal flight and while accelerating, he noticed high airplane nose-down control forces and that the airplane became increasingly difficult to control. He used manual trim to attempt to trim out the control forces and verified that the autopilot was not engaged; however, the nose-down tendency continued, and the pilot had trouble maintaining altitude. During the subsequent emergency landing, the airframe sustained substantial damage. Postaccident examination of the airplane revealed that the elevator trim push rod assembly was separated from the elevator trim tab actuator, and the end of the elevator trim push rod assembly was found wedged against the elevator's main spar. The elevator trim indicator in the cockpit was found in the nose-up stop position; however, the elevator trim tab was deflected 24° trailing edge up/airplane nose down (the maximum airplane nose-down setting is 6°). A drilled bolt was recovered from inside the right elevator; however, the associated washer, castellated nut, and cotter pin were not found. Examination of the bolt revealed that the threads were damaged and that the bolt hole on one of the clevis yoke halves exhibited deformation, consistent with the bolt separating. About 2 weeks before the accident, the pilot flew the airplane to a maintenance facility for an annual inspection. At that time, Airworthiness Directive (AD) 2016-07-24, which required installation of new hardware at both ends of the pushrod for the elevator trim tab, was overdue. While the airplane was in for the annual inspection, AD 2016-07-24 was superseded by AD 2016-17-08, which also required the installation of new hardware. The ADs were issued to prevent jamming of the elevator trim tab in a position outside the normal limits of travel due to the loss of the attachment hardware connecting the elevator trim tab actuator to the elevator trim tab push-pull rod, which could result in loss of airplane control. While in for the annual inspection, the airplane was stripped and painted, which would have required removal of the right elevator. Although the repair station personnel indicated that they did not disconnect the elevator trim pushrod from the elevator trim tab actuator when they painted the airplane, photographs taken of the airplane while it was undergoing inspection and painting revealed that the pushrod likely had been disconnected. The repair station owner reported that he reinstalled the right elevator and the elevator trim pushrod after the airplane was painted; however, he did not replace the hardware at either end of the pushrod as required by the ADs. Subsequently, the airplane was approved for return to service. After the annual inspection, no work, repairs, or adjustments were made to the elevator trim system. The airplane had accrued about 58 hours since the annual inspection at the time of the accident. Although reusing the self-locking nut might have resulted in it coming off by itself, the cotter pin should have prevented this from happening. Therefore, although the castellated self-locking nut, washer, and cotter pin normally used to secure the elevator trim pushrod at the elevator trim tab actuator were not found, given the evidence it is likely that the hardware, which was not the required hardware, was not properly secured at installation, which allowed it to separate in flight. It is also likely that the pushrod assembly then moved aft and jammed in a position well past the maximum nose-down trim setting, which rendered controlled flight impossible.

The pilot contacted air traffic control and requested clearance to taxi for departure approximately an hour after the scheduled departure time. About 4 minutes later, the flight
was cleared for takeoff. A witness observed the airplane as it taxied, and found it strange that the airplane did not stop and "rev up" its engines before takeoff. Instead, the airplane taxied into the runway and proceeded with the takeoff without stopping. The airplane took off quickly, within 100 yards of beginning the takeoff roll, became airborne, and entered a steep left bank. The bank steepened, and the airplane descended and impacted the ground. Post accident examination of the wreckage revealed that the pilot's four-point restraint was not fastened and that at least a portion of the cockpit flight control lock remained installed on the control column. One of the pre-takeoff checklist items was, "Flight controls - Unlocked - Full travel." The airplane was not equipped with a control lock design, which, according to the airframe manufacturer's previously issued service bulletins, would "minimize the possibility of the aircraft becoming airborne when take off is attempted with flight control locks inadvertently installed." In 1990, Transport Canada issued an airworthiness directive to ensure mandatory compliance with the service bulletins; however, the Federal Aviation Administration did not follow with a similar airworthiness directive until after the accident.

The pilot purchased the multiengine airplane about 18 months prior to the accident, and was conducting his first flight in the airplane, as he flew it from Georgia to Massachusetts. While en route, the airplane experienced a failure of the left engine. The airplane began maneuvering near an airport, as its groundspeed decreased from 173 miles per hour (mph) to 90 mph, 13 mph below the minimum single engine control speed. A witness reported that the airplane appeared to be attempting to land, when it banked to the left, and descended to the ground. The airplane impacted on a road, about 3 miles east-southeast of the airport. A 3-inch, by 2.5- inch hole was observed on the top of the left engine crankcase, and streaks of oil were present on the left gear door, left flap, and the left side of the fuselage. The number two connecting rod was fractured and heat distressed. The number 2 piston assembly was seized in the cylinder barrel. The airplane had been operated about 30 hours, during the 6 years prior to the accident, and it had not been flown since its most recent annual inspection, which was performed about 16 months prior to the accident. In addition, both engines were being operated beyond the manufacturer's recommended time between overhaul limits. The pilot did not possess a multiengine airplane rating. He attended an airplane type specific training course about 20 months prior to the accident. At that time, he reported 452 hours of total flight experience, with 0 hours of multiengine flight experience.

During takeoff from the departure airport, as the pilot advanced the throttles, the aircraft made a "sudden turn to the right." The pilot successfully aborted the takeoff, performed an engine run-up, and then took off without incident. The pilot experienced no anomalies during the second takeoff or the flight to the destination airport. As he reduced the power while in the traffic pattern, at the destination airport, the left engine accelerated to 60 percent power. The pilot reported to the tower that he had "one engine surging and another engine that seems like I lost control or speed." The pilot advanced and retarded the throttles and the engines responded appropriately, so he continued the approach. As the pilot flared the airplane for landing, the left engine surged to 65 percent power with the throttle lever in the "idle" position. The airplane immediately turned to the right; the right wing dropped and impacted the ground. Disassembly of the engines revealed no anomalies to account for surging, or for an uncommanded increase in power or lack of throttle response. Functional testing of the fuel control units and fuel pumps revealed the flight idle fuel flow rate was 237 and 312 pounds per hour (pph), for the left and right engines, respectively. These figures were higher than the new production specification of 214 pph. According to the manufacturer, flight idle fuel flow impacts thrust produced when the power levers are set to the flight idle position and differences in fuel flow can result in an asymmetrical thrust condition.

The pilot was conducting an instrument landing system approach during night instrument meteorological conditions. The airplane was observed to descend toward the runway threshold to an altitude consistent with the approach decision height. A witness reported that he heard the airplane overhead, and assumed that the pilot had performed a missed approach. He described the engine noise as "cruise power" and did not hear any unusual sounds. Shortly thereafter, he received a call from airport operations stating that an airplane had crashed. The airplane impacted the ground about 1/4 mile to the left of the runway centerline, about 3,500 feet beyond the approach end of the runway. Examination of the airplane did not reveal any pre-impact mechanical malfunctions. A weather observation taken around the time of the accident, included a visibility 1/2 statue mile in fog, and an indefinite ceiling at 100 feet. The witness described the weather at the time of the accident as thick fog, and "pitch black."

After a normal cross country flight, the airplane was on final approach for landing to runway 20, when the air traffic controller instructed the pilot to "go-around" because a preceding airplane had not cleared the runway. The airplane was observed to pitch up and enter a steep, almost 90 degree left bank. The passenger in the rear seat described the flights from and to BAF as "smooth." She stated she thought that the airplane would be landing; however, then realized the airplane was in a left turn. The airplane impacted on the roof of a commercial building, and came to rest upright on a heading of 020 degrees, in a parking lot, about 1/4 mile east of the approach end the runway. Examination of the airplane, which included a teardown of the engine, did not reveal evidence of any pre-impact malfunctions. Weather reported at the airport about the time of the accident included winds from 240 degrees at 7 knots; visibility 10 status miles and few clouds at 6,500 feet. The pilot owned the airplane and had accumulated about 1,660 hours of total flight experience.

The pilot accepted an intersection departure and waived the wake turbulence holding time. A Boeing 737-300 departed ahead of him, and according to pilot, the Boeing's nosewheel lifted off the runway just as it passed him. The pilot also noted that the Boeing and its exhaust smoke drifted to the left of the runway's centerline. A wake turbulence advisory and takeoff clearance were issued by the tower controller and acknowledged by the pilot. The pilot initiated the takeoff, and after liftoff, the left wing dropped. It contacted the runway, and the airplane rolled inverted. The airplane then slid off the left side of the runway and a post-crash fire developed.

The pilot departed his home airport for a 90 mile personal flight with eight passengers. The pilot stated he departed with 24 gallons of fuel in the outboard tanks, and 80 gallons of fuel in the main tanks. After landing, the airplane was refueled with 100 low-lead aviation gasoline; 12 gallons in each main fuel tank. Before departing for the return flight, the pilot performed a preflight inspection of the airplane, which did not include a visual check of the airplane's fuel tanks. After takeoff, the pilot experienced a "small surge in both engines," while climbing through 1,150 and 3,300 feet, respectively. He further described the surges as "minor but still noticeable." About 30 minutes later, after the airplane had descended, and was leveling at 1,500 feet, the pilot experienced an intermittent illumination of the "right aux fuel pump light," which was followed by a total loss of power on the right engine. Shortly thereafter, the left engine began "surging," and after about "three or four minutes, at most," he feathered the left engine propeller. The pilot ditched the airplane in Massachusetts Bay. The airplane was recovered about 1 month later. The fuel selectors were positioned to the outboard tanks, and the airplane's fuel tanks revealed fluid consistent with seawater with "some odor of fuel;" however, no visible evidence of fuel was observed. According to the airplane's information manual, the airplane's total fuel capacity was 192 gallons, of which, 182 gallons were usable. Examination of the airframe and engine did not reveal evidence of any pre-impact mechanical malfunctions. The pilot reported he had purchased the airplane and attended 5-day type specific training course in March 2001. He reported about 1,050 hours of total fight experience, which included 800 hours in multi-engine airplanes, of which 65 hours was in the make and model. Additionally, the pilot reported he had not experienced any prior mechanical problems. He believed he had flown the airplane the day prior to the accident as well. The last documented refueling of the airplane prior to the date of the accident occurred on May 3, 2001, when the airplane was refueled with 128 gallons of aviation gasoline. The last flight documented in the pilot's logbook was on May 4, 2001, when the pilot logged 1.9 hours in the accident airplane. The pilot said he normally flew a 65 percent power, an "a little rich," and experienced a fuel burn of about 20 to 21 gallons per hour, for each engine.

The pilot was conducting the localizer approach to runway 15 when the aircraft overran the runway and struck an obstacle. According to the pilot, a loss of power occurred in both engines as he attempted to do a missed approach, and the airspeed subsequently decreased from 105 to 80 knots. The pilot reported that he pushed the nose over to avoid a stall, broke out of the clouds over the mid-point of the runway, landed long and continued off the end of the runway into terrain and a tower structure. A witness reported the 'aircraft broke out of the clouds just above the trees north of runway 5 and west of runway 15. Reportedly, the aircraft as being banked from a right to left to get aligned with runway 5, flaps appeared to be up, and the gear was down. The witness said the engines sounded to be at idle and at high rpm, and the aircraft appeared to be 50 feet above the ground at midfield when it went out of sight behind hangar.' The weather observed at the time of the accident was in part: ceiling 100 feet overcast, visibility 0.5 mile with fog and rain. The published landing minimums for the approach was ceiling 400 feet and visibility 0.75 mile. Recorded radar data of the flight indicated a descent below the minimum descent altitude at a constant airspeed. Both engines started immediately and ran during a postaccident check of the aircraft.

The airplane was on an ILS runway 15 approach and collided in-flight with static wires, approximately 2 miles north of the runway. The wires were located in the airplane's flight path, and in a direct line with the ILS final approach course. At the time of the accident the local control tower was closed. Three other aircraft made the approach prior to N402BK, and the pilots of those aircraft all agreed that at about 500 to 700 feet msl, on the final approach course, they encountered downdrafts and turbulence. All the pilots agreed, the downdrafts caused their airplanes to fall below the glide slope, and that in order to rejoin the glide slope, they had to increase power or change the airplane's pitch attitude. The Otis Air National Guard Base 2155 weather observation was; indefinite ceiling 100 sky obscured, visibility 3/4 miles, light rain and fog, temperature 59° F, dew point 58° F, wind 170°, 14 knots, gust to 19, altimeter 29.96 inches hg.